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A Wake Up Safe Patient Safety Alert
Decreasing the Risks of Intravenous Medication Errors

UPDATE June 22, 2011

Wake up Safe has already issued a statement concerning medication errors (http://www.wakeupsafe.org/intravenousmederrors.iphtml), but we have now received many additional reports of problems with medications. We have received a total of 127 reports of serious adverse events occurring during anesthesia, and 23 of those reports are medication-related. With an approximate number of anesthetics of 250,000 in the institutions reporting to Wake up Safe, that suggests an incidence of serious medication errors of about 1 per 12,500 anesthetics. This finding confirms that medication-related events are an important problem in pediatric anesthesia, and the frequency of these events prompts us to issue another statement. It is likely that the total number of medication errors is much higher because Wake Up Safe institutions are only reporting errors that result in significant harm to the patient.

Of the 23 reports, 5 were wrong drug, 12 were wrong dose, 1 wrong route, 2 omissions of needed drugs, and 3 were possible adverse reactions.

Anesthesiologists are the only physicians who regularly give medications directly to patients. Furthermore, they are the only health care providers responsible for the entire medication delivery chain (order, prep, transport, administer, record, and monitor outcomes). Except when ordered medications are delivered in single unit doses from the pharmacy, the rapid paced nature of care in the operating room frequently precludes pre-administration double-checks commonly in place in other parts of the hospital.

Anesthesiologists have long known that safe management of medication is an important training topic, and pediatric anesthesiologists recognize the importance of training residents in safeguards that should be used when giving medications to children. Clearly from the reported events of medication errors, training alone is insufficient. Additional processes and tools should be explored to enhance medication safety in the OR.

The leadership of Wake up Safe feels that the Pediatric Anesthesia community should be aware of and vigilant for the problem of medication errors that occur during anesthesia in the OR. We invite practitioners and others to share solutions that they have developed to prevent medication errors in the OR. Please send your thoughts to directorWuS@pedsanesthesia.org.